Philadelphia University + Thomas Jefferson University

Student Survey Proposal Form

Please complete this form and submit all supporting documents to OIR@jefferson.edu.

 

Contact information: Office and person administering the survey:*

 

Please provide your email address.*

 

1. Describe the goals and objectives of your survey. Why are you conducting the survey and what do you hope to do with the results?



2. Who are the intended audience for the results?


3. Describe the survey method (i.e., web, paper and pencil, e-mail, phone, other).


4. Was this survey created internally or externally?

 Internal
 External


5. If this survey is part of a multi-institutional effort, have appropriate IRB processes been met at all institutions?

 Yes
 No


If "Yes", please list the name of other institution(s) involved:


6. Describe the survey timeline:

 
 
 


7. Describe the target population (both a description and a number).

(Population: the entire group of people about which you want to know something; e.g., all students on a college campus, those students that participated in a particular program, etc.)


8. Describe the sample (both a description and a number).

(Sample: the group of people selected from the population to which a survey will be administered)


9. Is this survey anonymous and/or confidential?

(Anonymous: the identity of respondent is unknown; Confidential: while the identity of the respondent is known, individual responses will not be made public and responses will be presented in statistical aggregate.)

 Anonymous
 Confidential

 

10. How will you be obtaining contact information of your sample?


11. Describe any incentives that will be used, if applicable.

 

12. Please provide a copy of the survey questionnaire. (You may type in the box, cut and paste the information, or send an email to OIR@jefferson.edu)

 

13. Please provide a copy of the cover letter that goes out with the survey, if applicable. (You may type in the box, cut and paste the information, or send an email to OIR@jefferson.edu)

 

14. Please provide a copy of the reminder letter. (You may type in the box, cut and paste the information, or send an email to OIR@jefferson.edu)

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